Provider Demographics
NPI:1215358981
Name:GOLLMAN, JACQUELINE BLUTCHER (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BLUTCHER
Last Name:GOLLMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:GOLLMAN
Other - Last Name:BLUTCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 290919
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33687-0919
Mailing Address - Country:US
Mailing Address - Phone:813-988-7844
Mailing Address - Fax:813-984-7161
Practice Address - Street 1:205 MARTIN LUTHER KING, JR. ST. NO.
Practice Address - Street 2:PINELLAS COUNTY HEALTH DEPARTMENT
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3109
Practice Address - Country:US
Practice Address - Phone:727-824-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0037797208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06973100Medicaid